Wednesday, August 3, 2011

Overmedicated and confused

"I take three blues at half past eight
to slow my exhalation rate.
On alternate nights at nine p.m.
I swallow pinkies. Four of them.
The reds, which make my eyebrows strong,
I eat like popcorn all day long.
The speckled browns are what I keep
beside my bed to make me sleep.
This long flat one is what I take
if I should die before I wake."
-Dr. Seuss

It may be in a children's picture book but this often reflects the truth. When I was on my geriatrics rotation, it was quite common to see patients on 15-20 different types of medications. In fact, it was rare to see patients who weren't on any.

The problem lies in the fact that often patients forget or refuse to take their medications. When a patient has 15 similar looking bottles, with similar looking pills and miniscular writing differentiating between the pills, this isn't surprising. Heck, I know that when I have to take one pill once a day for 2 weeks, I'll forget on at least 1 or 2 of those days. Not to mention when someone has some level of dementia and is somewhat sight impaired.

This doesn't even take into account that the directions that we write on the bottles (when the patient actually figures out how to read them) are just as confusing as not reading them. Take for example: "take three pills three times a day for 7 days." Does that mean I take 3 pills in the morning, 3 at noon and 3 before bed? Or 1 pill in the morning, 1 pill at noon and 1 pill at bedtime? Or should I space them out to exactly 8 hours apart?

With all this confusion, we've started developing pill organizers and blister packs. Either the patient, a loved one or the pharmacy will organize meds into AM, noon, PM and night time meds. However, studies have shown no difference in compliance levels from using pill organizers.

Ultimately, I believe that thinking of new ways to organize meds or remind patients is not the solution. The ultimate solution is that we need to re-evaluate each medication that each patient takes and try to focus on compliance with the most important of the meds. Does a 95 year old female need to be on a statin? Should a 30 year old male be taking calcium supplements? Maybe or maybe not. But as primary care doctors, it is our imperative to dive in deep and look at whether each and every medication is necessary - to stop specialists from piling on the meds for their unique specialty and to take a step back and look at the bigger picture.

Last week in my dermatology rotation, an attending physician was explaining to a patient's mother the treatment regimen for atopic dermatitis that he wanted to put her son on over an interpreter phone. The patient was to use triamcinolone when there was rash except on the face, tacrolimus on weekends only when there was no rash and hydrocortisone on the face with or without the rash. The poor resident typing the prescription had to ask the attending twice to clarify the correct directions. Now, what are the chances that the mother (a) understood what the doctor was telling her in a different language and/or (b) would be able to find someone to read the directions in English to her?

As physicians we must take a patient-centered approach to prescribing medications. What does the patient want? What is the patient willing to do? And before we get frustrated when a patient returns 2 months later "noncompliant" to our treatment regimen, we must also take a step back and reflect if we were the patients, whether we would be able to be "compliant" ourselves. This reflection will help us become more compassionate and more effective physicians.

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